Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
80 Cards in this Set
- Front
- Back
|
Case: 66 year old woman presents to your office with worsening shortness of breath, bilateral leg edema, and three-pillow orthopnea. She is not known to be hypertensive, but her BP is 187/90 and she is only saturating at 93% on room air. Her exam reveals JVD, a pansystolic murmur, and decreased breath sounds at both lung bases. On CXR you find bilateral pleural effusions and decide to admit her for further workup and management.
What is the most likely diagnosis? |
New-onset CHF |
|
|
Case: 66 year old woman presents to your office with worsening shortness of breath, bilateral leg edema, and three-pillow orthopnea. She is not known to be hypertensive, but her BP is 187/90 and she is only saturating at 93% on room air. Her exam reveals JVD, a pansystolic murmur, and decreased breath sounds at both lung bases. On CXR you find bilateral pleural effusions and decide to admit her for further workup and management.
What is the next diagnostic step? |
- Serial cardiac enzymes and ECGs - CBC, electrolytes, renal function - Echocardiogram |
|
|
Case: 66 year old woman presents to your office with worsening shortness of breath, bilateral leg edema, and three-pillow orthopnea. She is not known to be hypertensive, but her BP is 187/90 and she is only saturating at 93% on room air. Her exam reveals JVD, a pansystolic murmur, and decreased breath sounds at both lung bases. On CXR you find bilateral pleural effusions and decide to admit her for further workup and management.
How should she be treated initially? |
- Telemetry monitoring - IV diuretics - Oxygen |
|
|
What causes most cases of CHF? |
Coronary artery disease or hypertension |
|
|
What causes anxiety in patients with acute CHF? How does this affect the CHF? |
- Overloading of fluid in lungs commonly causes anxiety because of the struggle to oxygenate - Anxiety activates sympathetic pathways and mounts catecholamine-induced responses, which produces further worsening of acute CHF by causing tachycardia and increases PVR, leading to greater stress on the heart |
|
|
How can you suppress the anxiety response to acute CHF to prevent worsening? Mechanism? |
Morphine sulfate, actas as both an anxiolytic and a vasodilator |
|
|
What is the diuretic of choice in acute CHF? |
Lasix (Furosemide) - diuretic effect and immediate vasodilatory action on bronchial vasculature |
|
|
What other medications should eventually be started in a patient with acute CHF? |
- ACE-I - Beta-blockers
--> Decrease preload and after load and reduce cardiac remodeling |
|
|
What study identified the epidemiological risk factors associated with cardiovascular disease? |
Framingham Heart Study |
|
|
What are the two main categories of CHF? |
- Systolic dysfunction: dilated LV with impaired contractility - Diastolic dysfunction: normal or intact LV that has an impaired ability to relax, fill, and eject blood |
|
|
What are the common causes of cardiac rhythm disorders that can cause CHF? |
- Complete heart block - Supraventricular tachycardia - Ventricular tachycardia - Sinus node dysfunction |
|
|
What are the common causes of volume overload that can cause CHF? |
- Structural heart disease (ventricular septal defect, patent ductus arterioles, aortic or mitral regurgitation, complex cardiac lesion) - Anemia - Sepsis |
|
|
What are the common causes of pressure overload that can cause CHF? |
- Structural heart disease (aortic or pulmonary stenosis; aortic coarctation) - Hypertension |
|
|
What are the common causes of systolic ventricular dysfunction or failure causing CHF? |
- Myocarditis - Dilated cardiomyopathy - Malnutrition - Ischemia |
|
|
What are the common causes of diastolic ventricular dysfunction or failure causing CHF? |
- Hypertrophic cardiomyopathy - Restrictive cardiomyopathy |
|
|
What is the most sensitive symptom for the diagnosis of CHF? |
Dyspnea on exertion (however it is not very specific) |
|
|
What are common symptoms in CHF? |
- Dyspnea on exertion - Dyspnea at rest - Anxiety - Orthopnea - Paroxysmal nocturnal dyspnea - Cough productive of pink, frothy sputum - Weakness, lightheadedness, abdominal pain, malaise, wheezing, and nausea |
|
|
What history is common in patients with CHF? |
- Medical history of HTN, coronary artery disease, or other heart disease (cardiomyopathy, valvular disease, etc) - History of smoking and alcohol abuse may also be found |
|
|
What are the signs/symptoms of R sided heart failure? |
- Venous congestion - Nausea / vomiting - Distension / bloating - Constipation - Abdominal pain - Decreased appetite - Fluid retention - Weight gain - Peripheral edema - JVD - Hepatojugular reflux - Hepatic ascites - Splenomegaly |
|
|
What are the signs/symptoms of L sided heart failure? |
- Pulmonary congestion --> dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, wheezing, tachypnea, cough - Bilateral pulmonary rales - S3 gallop rhythm - Cheyne-Stokes respirations - Pleural effusion - Pulmonary edema |
|
|
What is often the first manifestation of congestive heart failure? |
Pulmonary edema |
|
|
What are the non-cardiac causes of pulmonary edema? |
- Direct injury to the lung - Hematogenous injury to lung - Possible lung injury plus elevated hydrostatic pressures |
|
|
What are some direct injuries to the lung(s) that can cause pulmonary edema? |
- Chest trauma - Aspiration - Smoke inhalation - Pneumonia - Oxygen toxicity - Pulmonary embolism |
|
|
What are some hematogenous injuries to the lung(s) that can cause pulmonary edema? |
- Sepsis - Pancreatitis - Non-thoracic trauma - Leukoagglutination reactions - Multiple transfusions - IV drug use - Cardiopulmonary bypass |
|
|
What are some possible injuries to the lung(s) + elevated hydrostatic pressures that can cause pulmonary edema? |
- High-altitude pulmonary edema - Neurogenic pulmonary edema - Re-expansion pulmonary edema |
|
|
What are the signs and symptoms consistent with both L & R heart failure? |
- Tachycardia - Cardiomegaly - Cyanosis - Oliguria - Nocturia - Peripheral edema - Weakness, fatigue, confusion (delirium), decreased mental status, insomnia, decreased exercise tolerance, headache, stupor, coma, paroxysmal nocturnal dyspnea, and declining functional status |
|
|
How can you diagnose CHF based on the Framingham Heart Study? |
Two major criteria OR one major and two minor criteria: - Major signs - paroxysmal nocturnal dyspnea, JVD, rales, cardiomegaly, pulmonary edema, S3 gallop, central venous pressure >16 cm H2O, circulation time of 25 seconds, hepatojugular reflex, weight loss of 4.5 lbs over 5 days of treatment - Minor signs - bilateral ankle edema, nocturnal cough, dyspnea on exertion, hepatomegaly, pleural effusion, decreased vital capacity by 1/3 max, and tachycardia |
|
|
How common is CHF among people 50-59 years? |
1-2% |
|
|
How common is CHF among people older than 65? |
6-10% |
|
|
How common is hospitalization among patients with CHF yearly? |
30-50% |
|
|
What is the leading diagnosis-related group (DRG) among hospitalized patients older than age 65 years? |
CHF |
|
|
What is the 5-year mortality rate for men and women with CHF? |
- Men: 60% - Women: 45% |
|
|
What is the median survival time for men and women with CHF? |
- Men: 3.2 years - Women: 5.4 years |
|
|
What is the most common cause of death in patients with CHF? |
Progressive heart failure, but sudden death may account for up to 45% of deaths |
|
|
How does the incidence of death from CHF in African Americans compare to in whites? |
African Americans are 1.5x more likely to die from CHF than whites
But they have similar or lower in hospital mortality rates |
|
|
How does the incidence of CHF differ by gender? |
- Between ages 40-75 years, men have a greater prevalence - After age 75 years, the prevalence has no difference |
|
|
What initial blood tests should you get in a patient you suspect of having CHF? |
- CBC - Serum electrolytes - Renal function tests - Hepatic function tests - Cardiac enzymes |
|
|
Why do you want to get a CBC in a patient who may have CHF? |
- Check white count - elevation suggests infection which is a common triggering event - Check H/H - anemia is another common trigger of CHF (d/t reduced O2 carrying ability causing need for increased CO) |
|
|
Why do you want to check electrolytes in a patient who may have CHF? |
Electrolyte abnormalities are common in the presence of CHF
Responses to a failing heart leads to water and sodium retention and potassium excretion --> may lead to dilutional hyponatremia
Meds used by patients with CHF also can cause abnormalities |
|
|
Why do you want to check liver enzymes in a patient who may have CHF? |
Increased vascular congestion can lead to passive congestion of the liver, resulting in increases in serum transaminases; it can even cause jaundice |
|
|
Why do you want to check cardiac enzymes in a patient who may have CHF? |
Evaluate for the presence of acute MI as the inciting event |
|
|
What blood test will be abnormal in CHF due to a failing ventricle? |
Elevated BNP (Brain Natriuretic Peptide) and pro-BNP found in CHF
Neurohormonal response to the presence of a failing ventricle is release of BNP |
|
|
Quantitatively, how can you use BNP to help you diagnose CHF? |
In a patient with dyspnea, a BNP level <100 pg/mL suggests symptoms are unlikely to be caused by CHF but a BNP >500 pg/mL is consistent with the diagnosis |
|
|
Why should you get an EKG in a patient who may have CHF? |
EKG findings are variable in CHF: - Useful to evaluate for evidence of acute ischemia or arrhythmia as the cause of CHF - Can also reveal the presence of ventricular hypertrophy, often seen in chronic HTN |
|
|
Why should you get a CXR in a patient who may have CHF? |
- CXR can show cardiomegaly and cardiac chamber enlargement (typically the cardiothoracic ratio is >50%) - Early sign is cephalization of the pulmonary vasculature --> interstitial pulmonary edema can be seen as perihilar infiltrates, often in a butterfly pattern - Pleural effusions can also be found (likely bilateral, but R hemithorax more often seen than L) |
|
|
What is the gold standard for diagnosing the presence of CHF? |
Echocardiography |
|
|
What are you looking for on echo in a patient you suspect of having CHF? |
Identify regional or global wall motion abnormalities, cardiomyopathy, ventricular or septal hypertrophy, cardiac ejection fraction
Can also identify cardiac tamponade, pericardial constriction, and pulmonary embolus
Can also identify valvular disease like stenosis or regurgitation, which can lead to heart failure |
|
|
How can you classify heart failure? |
Characterized by the symptoms and degree of symptoms that limit the patient's lifestyle
New York Heart Association (NYHA) and American Heart Association (AHA) classifications |
|
|
How would you classify a patient with no physical limitations and only risk factors for CHF? |
American Heart Association: A New York Heart Association: - |
|
|
How would you classify a patient with no limitations with normal activities and symptoms of LV dysfunction? |
American Heart Association: B New York Heart Association: I |
|
|
How would you classify a patient with mild limitations and fatigue and dyspnea with normal activities? |
American Heart Association: B New York Heart Association: II |
|
|
How would you classify a patient with moderate limitations and symptoms with activities of daily living? |
American Heart Association: C New York Heart Association: III |
|
|
How would you classify a patient with severe limitations and symptoms at rest? |
American Heart Association: D New York Heart Association: IV |
|
|
How can you assist breathing in a patient with CHF? |
- Give supplemental O2 - If necessary, ventilation with continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or mechanical ventilation |
|
|
What should you do to treat a patient with acute pulmonary edema caused by CHF? |
Administer loop diuretic (lasix) - potent diuretic effect and rapid bronchial vascular vasodilation |
|
|
What medication can reduce preload and afterload in patients with CHF? |
Nitrates (particularly Nitroglycerin when given IV) reduce myocardial O2 demand by reducing preload and after load; also can rapidly reduce BP |
|
|
What medication is indicated to lower an elevated BP in a patient with CHF? |
Nitroglycerin |
|
|
What is the mechanism and utility of Morphine Sulfate in a patient with CHF exacerbation? |
- Analgesic and anxiolytic properties - Venodilator (primary effect) and arterial dilator --> reduced preload and increased cardiac output |
|
|
What are the discharge criteria from the ED for a patient with CHF? |
- Gradual onset of symptoms - Rapid resolution of symptoms with treatment - O2 saturation >90% on room air - Exclusion of an acute coronary syndrome as cause of CHF |
|
|
What patient education is important for patients with CHF? |
- Dietary sodium and fluid restriction - Overweight and obese patients should be counseled on calorie restriction and encourage exercise to lose weight - Strict management of BP and modification of other cardiac risk factors |
|
|
What is the normal sodium intake in the U.S.? What should a patient with CHF have as their intake? |
- Normal intake: 6-10g NaCl / day - CHF patient: 2-4g NaCl / day (more strict may be necessary if more severe disease) |
|
|
What long-term drug should be considered first-line therapy for patients with CHF and reduced LV function? |
ACE-I --> reduces preload, afterload, improves cardiac output, and inhibits tissue renin-angiotension systems |
|
|
What are the benefits of ACE-I or ARBs in patients with CHF? |
- Improvement in symptoms - Reduction in mortality - Delay development of symptomatic CHF in asymptomatic patients with a reduced cardiac EF |
|
|
When are ACE-I contraindicated? |
- Pregnancy - Hypotension - Hyperkalemia - Bilateral renal artery stenosis - Use with caution in patients with renal insufficency |
|
|
Should beta-blockers be started during an exacerbation of CHF? Why or why not? |
No - may worsen symptoms from both systolic and diastolic heart failure |
|
|
How and when should beta-blockers be started for patients with CHF? |
Start low and titrate up over several weeks - Primarily indicated for patients with NYHA class II or III or in patients with CAD |
|
|
What are the benefits of beta-blockers in patients with CHF? |
- Reduce sympathetic tone - Reduce cardiac muscle remodeling associated with cHF - Reduces mortality in patients with EF <35% - Primarily indicated for patients with NYHA class II or III or in patients with CAD |
|
|
When should diuretics be used for CHF? |
In both acute and chronic settings in all stages of CHF |
|
|
What diuretics should be used for CHF? |
- Loop diuretics are best (furosemide, bumetanide, torsemide, ethacrynic acid) - Thiazide diuretics (hydrochlorothiazide, chlorthalidone, others) used in mild heart failure and may be used in combination with other diuretics in severe CHF - Adjust doses based on daily weight measurements by patient |
|
|
What med should be added for patients in NYHA class III or IV to improve survival benefit? Mechanism? |
Spironolactone - aldosterone antagonist |
|
|
What are the effects of spironolactone in CHF? |
- Reduces mortality in advanced heart failure - Functions as a diuretic - May cause hyperkalemia (may be profound and could lead to arrhythmias) |
|
|
What medication are typically contraindicated in systolic CHF? Why? |
Calcium channel blockers, in general, are contraindicated in systolic HF because they increase mortality (the exception is Amlodipine / Norvasc, which does not increase or decrease mortality) |
|
|
When can calcium channel blockers be used in patient with CHF? |
- Generally contraindicated d/t increased mortality in patients with systolic CHF, with exception of Amlodipine (Norvasc) - In diastolic CHF Diltiazem and Verapamil are useful because they promote increased cardiac output by lowering HR, which allows more ventricular filling time |
|
|
How common is ECG evidence of abnormal ventricular conduction (i.e., prolonged QRS duration) in patients with NYHA class III or IV CHF? |
About 1/3 |
|
|
How can you help treat patients with evidence of abnormal ventricular conduction and CHF? |
Promote synchronous contraction of both R and L ventricles using biventricular pacemaker = Cardiac Resynchronization Therapy = reduces mortality and hospitalization in patients with symptomatic CHF in spite of maximal medical therapy |
|
|
A 57-year old man who has known NYHA class II heart failure presents to clinic after noting to become dyspneic with significant exertion. On exam, his BP is 140/86, pulse is 86 bp, RR 20 bp. A 2/6 pan systolic murmur is best heard of the right sternal border. There is no JVD, but 1+ pre-tibial and pedal edema are noted. He currently takes ACE-i and aspirin. Which one of the following additional meds have been shown to improve longevity in this situation? a) warfarin b) digitalis c) beta-blocker d) nondihydropyridine CCB e) amiodarone |
Beta-blocker
Recommended to reduce mortality in symptomatic patients with CHF. Because polypharmacy can reduce compliance, the role that digoxin plays in HF management is unclear. CCBs should be used in caution with heart failure because they can cause peripheral vasodilation, decreased HR, decreased contractility, and decreased cardiac conduction |
|
|
A 52-year old man with a long-standing hx of marginally controlled HTN presents with gradually increasing SOB and reduced exercise tolerance with pain in his calves that causes him to stop walking after one block. His meds include enalapril and metoprolol. Exam reveals BP 140/90, RR of 22 bp, HR 88 bp. Bibasilar rales, trace pitting edema, posterior tibial and dorsalis pedis pulses are 1+.
What is the most appropriate diagnostic test right now? |
2D echo with Doppler
Assess LV EF, size, compliance, wall thickness, and valve function
Should be performed during initial evaluation. CXR and 12-lead EKG should be performed in all patients presenting with CHF but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure. |
|
|
A 64-year old man is noted to have CHF because of CAD. Over past 2 days, he has developed progressive dyspnea and orthopnea. On exam, he is found to be in moderate respiratory distress, has JVD, and rales. He is diagnosed with pulmonary edema.
What drug is most appropriate at this time? |
Lasix / Furosemide |
|
|
A 70-year old African-American man with NYHA class III CHF sees you for F/U. He has SOB w/ minimal exertion. Pt is adherent to his meds. He takes lisinopril 40 mg BID, carvedilol 25 mg BID, and lasix 80 mg daily. His BP is 100/60 and HR is 70 bp and regular. Exam findings include a few scattered bibasilar rales, an S3 gallop, and no peripheral edema. An ECG reveals a left bundle branch block and echo reveals an EF of 25%.
What is the next step in treatment? |
Refer for cardiac resynchronization therapy
This patient is already receiving max medical therapy. This therapy is recommended for patients with medical refractory, symptomatic, NYHA Class III or IV with a QRS interval >130 ms, a LV end-diastolic diameter of >55 mm, and a LV EF <30% |
|
|
Who are the optimal candidates for CRT (cardiac resynchronization therapy)? |
Patients with a dilated cardiomyopathy on an ischemic or non-ischemic basis, an LVEF ≤35%, a QRS complex ≥120 ms with sinus rhythm, and are NYHA Class III or IV despite max medical treatment for CHF |
